DOCSLIB.ORG

Flushing -- Print Version

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Flushing -- Print Version Flushing -- Print Version TITLE: FLUSHING AUTHOR: CHRISTIAN NASR, MD -- Department of Endocrinology PUBLISHED: DECEMBER 7, 2004 Print Tables From This Chapter DEFINITION Flushing describes episodic attacks of redness of the skin together with a sensation of warmth or burning of the face, neck, and less frequently the upper trunk and abdomen. It is the transient nature of the attacks that distinguishes flushing from the persistent erythema of photosensitivity or acute contact reactions. Repeated flushing over a prolonged period of time can lead to telangiectasia and occasionally to classical rosacea of the face.1 Flushing can be an exaggeration of a physiological process or a manifestation of a serious condition that needs to be identified and treated. A biochemical work-up of every case of flushing is neither practical nor cost-effective; in this chapter, the author will present guidelines that will help determine when a work- up is warranted. PREVALENCE The prevalence of flushing has not been determined. PATHOPHYSIOLOGY Redness of the skin may be due to an increased amount of saturated hemoglobin, an increase in the diameter or actual number of skin capillaries, or a combination of these factors.2 Flushing is due to increased blood flow through the skin, causing warmth, and because of engorgement of the subpapillary venous plexus, redness. The vasodilatation of flushing may be due to a direct action of a circulatory vasodilator substance, for example histamine, or it may be caused by changes in the neurological control of the cutaneous vasculature in the affected areas. In the face, neck, and upper trunk, where flushing is most frequent, the neurological control of vascular tone is predominantly exerted by autonomic vasodilator nerve fibers. These fibers are found in somatic nerves supplying the affected skin, including the trigeminal nerve. Since autonomic nerve fibers also supply eccrine sweat glands, neurally activated flushing is frequently associated with sweating (wet flushing) as opposed to flushing due to circulating vasodilator mediators which frequently does not involve sweating (dry flushing). The presence or absence of sweating has therefore been proposed as a clinical guide to the mechanisms of flushing, although in practice this is not always reliable. Examples of wet flushing are physiological flushing and menopausal flushing. An example of dry flushing is niacin-provoked flushing.1 The diameter of the blood vessels of the cheeks is wider than elsewhere, the vessels are nearer to the http://www.clevelandclinicmeded.com/medicalpubs/...emanagement/endocrinology/flushing/flushing1.htm (1 of 11) [9/18/2007 3:18:27 PM] Flushing -- Print Version surface, and there is less tissue thickness obscuring them. This may explain why flushing occurs in that limited distribution.3 Polycythemia produces the characteristic ruddy complexion, but it may also cause a peculiar coloration termed "erythremia," which is a combination of redness and cyanosis. The tongue, lips, nose, earlobes, conjunctivae, and fingertips especially demonstrate this coloration. Erythremia results when there is a combination of increased amounts of saturated hemoglobin and desaturated hemoglobin. In some carcinoid tumors, fibrosis of the right side of the heart may lead to a combination of stenosis and regurgitation at the tricuspid valve as well as pulmonary stenosis. If cyanosis occurs, the combination of flushing and cyanosis may produce the reddish cyanotic erythremia.2 FLUSHING SYNDROMES Physiological Flushing: Embarrassment or anger may cause flushing in some individuals in whom the threshold for this response may be low or the reaction itself unusually intense; this is also known as blushing.1,2 Explanation and reassurance are usually sufficient. If necessary, propranolol or nadolol may be used to alleviate the symptom.1 Heat causes flushing in many patients, and overheating can lower the threshold to flushing due to other causes such as menopause.3 Overheating such as after exercise or sauna can cause physiological flushing due to the effect of the rise in blood temperature on the thermoregulatory center in the anterior hypothalamus. A similar mechanism is responsible for facial flushing due to hot drinks, which cause a rise in temperature of blood in the oral cavity in turn leading to a rise in temperature of blood perfusing the hypothalamus. The temperature of hot coffee rather than its caffeine causes flushing. A useful maneuver for patients faced with a brief thermal exposure is to suck on ice chips carried in an insulated cup. This will attenuate flushing for the first 20 to 30 minutes.3 Menopausal Flushing: About 80% of postmenopausal women experience flushing associated with sweating. A similar syndrome may also occur in men with prostate cancer receiving treatment with gonadotropin-releasing hormone analogs such as buserelin. About 65% of post-menopausal women have hot flushes for 1 to 5 years, 26% for 6 to 10 years, and 10% for more than 11 years. There is considerable variation in the frequency, intensity, and duration of hot flushes within and among individuals. A typical hot flush begins with a sensation of warmth in the head and face, followed by facial flushing that may radiate down the neck and to other parts of the body; it is associated with an increase in temperature and pulse rate and followed by a decline in temperature and profuse perspiration over the area of flush distribution. Visible changes occur in about 50% of women. Each hot flush lasts for 1 to 5 minutes. The primary role of estrogen deficiency has been questioned and a deficit of thermoregulation has been proposed. Rapid estrogen withdrawal rather than a low estrogen level by itself is likely to induce hot flushes.4 Synchronous with the onset of each hot flush is the release of a pulse of luteinizing hormone; this does not seem responsible for the hot flush since flushing can occur after hypophysectomy. The anterior hypothalamus has estrogen and progesterone receptors, and both hormones can be used effectively to http://www.clevelandclinicmeded.com/medicalpubs/...emanagement/endocrinology/flushing/flushing1.htm (2 of 11) [9/18/2007 3:18:27 PM] Flushing -- Print Version treat hot flushes through binding with their respective hypothalamic receptors. Neurotransmitters that may be involved in the pathogenesis of hot flushes include norepinephrine and other noradrenergic substances. The central noradrenergic system in the hypothalamus triggers the hot flushes via α2- adrenergic receptors on the noradrenergic neurons. Thus, clonidine—an α2-adrenergic agonist— effectively alleviates hot flushes through reduction of noradrenergic release.4 Pharmacologic menopause with flushing can be induced by a variety of drugs: 4- hydroxyandrostenedione, danazol, tamoxifen, clomiphene citrate and leuprolide. Certain characteristics suggest the diagnosis of climacteric flushing: drenching perspiration, a prodromal sensation of overheating before the onset of flushing and sweating, and waking episodes at night with the typical symptoms. Alcohol can enhance a menopausal flush.5 Veralipride, an antidopaminergic drug, can cause a reduction in the frequency and intensity of menopausal flushing in premenopausal women pretreated with goserelin (gonadotropin-releasing hormone agonist) for endometriosis.6 Flushing Caused by Drugs: Other medications that can cause flushing are corticotropin-releasing hormone, doxorubicin, and niacin (Table 2). Flushing is a side effect of sildenafil citrate in 12% of patients.7 Systemic administration of morphine can cause flushing of the face, neck, and upper thorax, which is thought to be histamine- mediated.5 Patients can develop facial flushing and/or generalized erythema after epidural or intra- articular administration of glucocorticoids. The exact pathophysiology is unclear but it could be related to distention of the joint capsule.8 Flushing Associated with Alcohol Intake: Certain oriental genotypes show extensive flushing in response to low doses of alcohol. They have been found to have higher plasma levels of acetaldehyde. This abnormality is probably related to a deficiency of an isoenzyme of liver aldehyde dehydrogenase. This population can be detected by using an ethanol patch test which produces localized erythema. A special type of alcohol flush is also associated with chlorpropamide, the oral anti-hyperglycemic agent. Even small amounts of alcohol provoke intense flushing within a few minutes of ingestion. This flushing is not associated with sweating, but in some cases tachycardia, tachypnea, and hypotension may be seen. The flush is mediated by elevated acetaldehyde plasma levels and possibly by release of prostaglandins. Alcohol ingestion can trigger flushing in carcinoid tumors, mastocytosis, medullary thyroid carcinoma, and certain lymphoid tumors. Trichloroethylene, a chemical that has been abandoned in recent years because of carcinogenic potential, can cause flushing. When inhaled following ingestion of alcoholic beverages, a striking cutaneous reaction results, consisting in the sudden appearance of erythema of the face, neck, and shoulders—a reaction that has been termed "degreaser's flush." Nausea and vomiting may also occur.5 Flushing Associated with Food: Eating spicy or sour foods can cause facial flushing. This gustatory flushing is due to a neural reflex http://www.clevelandclinicmeded.com/medicalpubs/...emanagement/endocrinology/flushing/flushing1.htm (3 of 11) [9/18/2007 3:18:27 PM] Flushing -- Print Version involving autonomic
Load more

Recommended publications
  • Carcinoid) Tumours Gastroenteropancreatic
    Downloaded from gut.bmjjournals.com on 8 September 2005 Guidelines for the management of gastroenteropancreatic neuroendocrine (including carcinoid) tumours J K Ramage, A H G Davies, J Ardill, N Bax, M Caplin, A Grossman, R Hawkins, A M McNicol, N Reed, R Sutton, R Thakker, S Aylwin, D Breen, K Britton, K Buchanan, P Corrie, A Gillams, V Lewington, D McCance, K Meeran, A Watkinson and on behalf of UKNETwork for neuroendocrine tumours Gut 2005;54;1-16 doi:10.1136/gut.2004.053314 Updated information and services can be found at: http://gut.bmjjournals.com/cgi/content/full/54/suppl_4/iv1 These include: References This article cites 201 articles, 41 of which can be accessed free at: http://gut.bmjjournals.com/cgi/content/full/54/suppl_4/iv1#BIBL Rapid responses You can respond to this article at: http://gut.bmjjournals.com/cgi/eletter-submit/54/suppl_4/iv1 Email alerting Receive free email alerts when new articles cite this article - sign up in the box at the service top right corner of the article Topic collections Articles on similar topics can be found in the following collections Stomach and duodenum (510 articles) Pancreas and biliary tract (332 articles) Guidelines (374 articles) Cancer: gastroenterological (1043 articles) Liver, including hepatitis (800 articles) Notes To order reprints of this article go to: http://www.bmjjournals.com/cgi/reprintform To subscribe to Gut go to: http://www.bmjjournals.com/subscriptions/ Downloaded from gut.bmjjournals.com on 8 September 2005 iv1 GUIDELINES Guidelines for the management of gastroenteropancreatic neuroendocrine (including carcinoid) tumours J K Ramage*, A H G Davies*, J ArdillÀ, N BaxÀ, M CaplinÀ, A GrossmanÀ, R HawkinsÀ, A M McNicolÀ, N ReedÀ, R Sutton`, R ThakkerÀ, S Aylwin`, D Breen`, K Britton`, K Buchanan`, P Corrie`, A Gillams`, V Lewington`, D McCance`, K Meeran`, A Watkinson`, on behalf of UKNETwork for neuroendocrine tumours ..............................................................................................................................
    [Show full text]
  • Differentiating Between Anxiety, Syncope & Anaphylaxis
    Differentiating between anxiety, syncope & anaphylaxis Dr. Réka Gustafson Medical Health Officer Vancouver Coastal Health Introduction Anaphylaxis is a rare but much feared side-effect of vaccination. Most vaccine providers will never see a case of true anaphylaxis due to vaccination, but need to be prepared to diagnose and respond to this medical emergency. Since anaphylaxis is so rare, most of us rely on guidelines to assist us in assessment and response. Due to the highly variable presentation, and absence of clinical trials, guidelines are by necessity often vague and very conservative. Guidelines are no substitute for good clinical judgment. Anaphylaxis Guidelines • “Anaphylaxis is a potentially life-threatening IgE mediated allergic reaction” – How many people die or have died from anaphylaxis after immunization? Can we predict who is likely to die from anaphylaxis? • “Anaphylaxis is one of the rarer events reported in the post-marketing surveillance” – How rare? Will I or my colleagues ever see a case? • “Changes develop over several minutes” – What is “several”? 1, 2, 10, 20 minutes? • “Even when there are mild symptoms initially, there is a potential for progression to a severe and even irreversible outcome” – Do I park my clinical judgment at the door? What do I look for in my clinical assessment? • “Fatalities during anaphylaxis usually result from delayed administration of epinephrine and from severe cardiac and respiratory complications. “ – What is delayed? How much time do I have? What is anaphylaxis? •an acute, potentially
    [Show full text]
  • Review Cutaneous Patterns Are Often the Only Clue to a a R T I C L E Complex Underlying Vascular Pathology
    pp11 - 46 ABstract Review Cutaneous patterns are often the only clue to a A R T I C L E complex underlying vascular pathology. Reticulate pattern is probably one of the most important DERMATOLOGICAL dermatological signs of venous or arterial pathology involving the cutaneous microvasculature and its MANIFESTATIONS OF VENOUS presence may be the only sign of an important underlying pathology. Vascular malformations such DISEASE. PART II: Reticulate as cutis marmorata congenita telangiectasia, benign forms of livedo reticularis, and sinister conditions eruptions such as Sneddon’s syndrome can all present with a reticulate eruption. The literature dealing with this KUROSH PARSI MBBS, MSc (Med), FACP, FACD subject is confusing and full of inaccuracies. Terms Departments of Dermatology, St. Vincent’s Hospital & such as livedo reticularis, livedo racemosa, cutis Sydney Children’s Hospital, Sydney, Australia marmorata and retiform purpura have all been used to describe the same or entirely different conditions. To our knowledge, there are no published systematic reviews of reticulate eruptions in the medical Introduction literature. he reticulate pattern is probably one of the most This article is the second in a series of papers important dermatological signs that signifies the describing the dermatological manifestations of involvement of the underlying vascular networks venous disease. Given the wide scope of phlebology T and its overlap with many other specialties, this review and the cutaneous vasculature. It is seen in benign forms was divided into multiple instalments. We dedicated of livedo reticularis and in more sinister conditions such this instalment to demystifying the reticulate as Sneddon’s syndrome. There is considerable confusion pattern.
    [Show full text]
  • Carcinoid Case Presentation and Discussion: the American Perspective
    Endocrine-Related Cancer (2003) 10 489–496 NEUROENDOCRINE TUMOURS Carcinoid case presentation and discussion: the American perspective R R P Warner Department of Medicine, Gastrointestinal Division, The Mount Sinai School of Medicine, One Gustave L Levy Place, New York, New York 10029, USA (Requests for offprints should be addressed toRRPWarner; Email: rwarner—[email protected]) Abstract The rationale underlying an aggressive approach in the management of some carcinoid patients is explained and illustrated by the presented case of a middle-aged man with advanced classic typical midgut carcinoid. The patient exhibited somatostatin receptor scintigraphy-positive massive liver metastases, carcinoid syndrome, severe tricuspid and pulmonic cardiac valve disease with congestive heart failure, ascites and malnutrition. He had been treated for several years with supportive medications and biotherapy including octreotide and alpha interferon but his tumor eventually progressed and his overall condition was markedly deteriorated when he first sought more aggressive treatment. This consisted of prompt replacement of both tricuspid and pulmonic valves, followed by hepatic artery chemoembolus (HACE) injection and then surgical tumor debulking including excision of the primary tumor in the small intestine. In addition, radiofrequency ablation was utilized to reduce the volume of metastases in the liver. Prophylactic cholecystectomy was also performed and a biopsy of tumor was submitted for cell culture drug resistance testing. This was followed by systemic chemotherapy utilizing the drug (docetaxel) which the in vitro studies suggested as most likely to be effective. His excellent response to this succession of treatments exemplifies the successful application of aggressive sequential multi-modality therapy. Endocrine-Related Cancer (2003) 10 489–496 Introduction and sometimes aggressive treatment (O¨ berg 1998).
    [Show full text]
  • Skin Manifestations of Illicit Drug Use Manifestações Cutâneas
    RevABDV81N4.qxd 12.08.06 13:10 Page 307 307 Educação Médica Continuada Manifestações cutâneas decorrentes do uso de drogas ilícitas Skin manifestations of illicit drug use Bernardo Gontijo 1 Flávia Vasques Bittencourt 2 Lívia Flávia Sebe Lourenço 3 Resumo: O uso e abuso de drogas ilícitas é um problema significativo e de abrangência mun- dial. A Organização das Nações Unidas estima que 5% da população mundial entre os 15 e 64 anos fazem uso de drogas pelo menos uma vez por ano (prevalência anual), sendo que meta- de destes usam regularmente, isto é, pelo menos uma vez por mês. Muitos dos eventos adver- sos das drogas ilícitas surgem na pele, o que torna fundamental que o dermatologista esteja familiarizado com essas alterações. Palavras-chave: Drogas ilícitas; Drogas ilícitas/história; Drogas ilícitas/efeitos adversos; Pele; Revisão Abstract: Illicit drug use and abuse is a major problem all over the world. The United Nations estimates that 5% of world population (aged 15-64 years) use illicit drugs at least once a year (annual prevalence) and half of them use drugs regularly, that is, at least once a month. Many adverse events of illicit drugs arise on the skin and therefore dermatologists should be aware of these changes. Keywords: Street drugs; Street drugs/history; Street drugs/adverse effects; Skin; Review HISTÓRICO Há mais de cinco mil anos na Mesopotâmia, minorar o sofrimento dos condenados. região onde hoje se situa o Iraque, os poderes cal- Provavelmente seja o ópio a droga nephente à qual mantes, soníferos e anestésicos do ópio (do latim Homero se referia como “o mais poderoso destrui- opium, através do grego opion, ‘seiva, suco’) já eram dor de mágoas”.1,2 conhecidos pelos sumérios.
    [Show full text]
  • Quick Tips on Recognizing Cutaneous Manifestations of Systemic Disease
    FEATURE ARTICLE 2.0 Quick Tips on Recognizing Contact Hours Cutaneous Manifestations of Systemic Disease Jennifer Cittadino ABSTRACT: Although many skin manifestations are isolated This article will concentrate on nonmalignant cutaneous to a dermatological disorder, some skin manifestations can manifestations of systemic disease. The body systems will berelatedtoadeeper,moresystemicissue.Theskinis be reviewed, and their associated skin manifestations will be related to other body systems and functions. The impor- discussed. Some of the skin manifestations can be seen in tance of being able to recognize these dermatological multiple systemic disorders, such as erythema nodosum, manifestations and associate them with potential systemic which can be seen in pulmonary disorders, collagen and disease can be a critical diagnostic tool for the practitioner. vascular disorders, and gastrointestinal disorders. Pictures Sometimes, these skin manifestations can be the first sign will be provided when possible. of an internal disease. Although challenging, recognition, prompt diagnosis, and treatment can alter the course of a CARDIOVASCULAR AND PULMONARY SYSTEM life-threatening illness. There are several general cutaneous signs of cardiovascular Key words: Cutaneous, Dermatology, Systemic, Skin disease that may commonly be seen. These findings may include edema, cyanosis, clubbing of the nails, and corneal he skin is the largest organ in the body and one arcus. The corneal arcus appears as a gray-white ring around of the most visible body systems. The skin has the cornea and correlates with age and cholesterol levels. a reciprocal relationship between what is visu- A diagonal earlobe crease is also reported to be a marker for alized on the surface and what is occurring coronary artery disease (Uliasz & Lebwohl, 2008).
    [Show full text]
  • What Is a Gastrointestinal Carcinoid Tumor?
    cancer.org | 1.800.227.2345 About Gastrointestinal Carcinoid Tumors Overview and Types If you have been diagnosed with a gastrointestinal carcinoid tumor or are worried about it, you likely have a lot of questions. Learning some basics is a good place to start. ● What Is a Gastrointestinal Carcinoid Tumor? Research and Statistics See the latest estimates for new cases of gastrointestinal carcinoid tumor in the US and what research is currently being done. ● Key Statistics About Gastrointestinal Carcinoid Tumors ● What’s New in Gastrointestinal Carcinoid Tumor Research? What Is a Gastrointestinal Carcinoid Tumor? Gastrointestinal carcinoid tumors are a type of cancer that forms in the lining of the gastrointestinal (GI) tract. Cancer starts when cells begin to grow out of control. To learn more about what cancer is and how it can grow and spread, see What Is Cancer?1 1 ____________________________________________________________________________________American Cancer Society cancer.org | 1.800.227.2345 To understand gastrointestinal carcinoid tumors, it helps to know about the gastrointestinal system, as well as the neuroendocrine system. The gastrointestinal system The gastrointestinal (GI) system, also known as the digestive system, processes food for energy and rids the body of solid waste. After food is chewed and swallowed, it enters the esophagus. This tube carries food through the neck and chest to the stomach. The esophagus joins the stomachjust beneath the diaphragm (the breathing muscle under the lungs). The stomach is a sac that holds food and begins the digestive process by secreting gastric juice. The food and gastric juices are mixed into a thick fluid, which then empties into the small intestine.
    [Show full text]
  • Familial Occurrence of Carcinoid Tumors and Association with Other Malignant Neoplasms1
    Vol. 8, 715–719, August 1999 Cancer Epidemiology, Biomarkers & Prevention 715 Familial Occurrence of Carcinoid Tumors and Association with Other Malignant Neoplasms1 Dusica Babovic-Vuksanovic, Costas L. Constantinou, tomies (3). The most frequent sites for carcinoid tumors are the Joseph Rubin, Charles M. Rowland, Daniel J. Schaid, gastrointestinal tract (73–85%) and the bronchopulmonary sys- and Pamela S. Karnes2 tem (10–28.7%). Carcinoids are occasionally found in the Departments of Medical Genetics [D. B-V., P. S. K.] and Medical Oncology larynx, thymus, kidney, ovary, prostate, and skin (4, 5). Ade- [C. L. C., J. R.] and Section of Biostatistics [C. M. R., D. J. S.], Mayo Clinic nocarcinomas and carcinoids are the most common malignan- and Mayo Foundation, Rochester, Minnesota 55905 cies in the small intestine in adults (6, 7). In children, they rank second behind lymphoma among alimentary tract malignancies (8). Carcinoids appear to have increased in incidence during the Abstract past 20 years (5). Carcinoid tumors are generally thought to be sporadic, Carcinoid tumors were originally thought to possess a very except for a small proportion that occur as a part of low metastatic potential. In recent years, their natural history multiple endocrine neoplasia syndromes. Data regarding and malignant potential have become better understood (9). In the familial occurrence of carcinoid as well as its ;40% of patients, metastases are already evident at the time of potential association with other neoplasms are limited. A diagnosis. The overall 5-year survival rate of all carcinoid chart review was conducted on patients indexed for tumors, regardless of site, is ;50% (5).
    [Show full text]
  • Carcinoid Syndrome Caused by a Serotonin-Secreting Pituitary Tumour
    L A Lyngga˚ rd and others Carcinoid syndrome from 170:2 K5–K9 Case Report pituitary tumour Carcinoid syndrome caused by a serotonin-secreting pituitary tumour Correspondence ˚ Louise A Lynggard, Eigil Husted Nielsen and Peter Laurberg should be addressed Department of Endocrinology, Aalborg University Hospital, Hobrovej 18-22, DK-9000 Aalborg, Denmark to P Laurberg Email [email protected] Abstract Background: Neuroendocrine tumours are most frequently located in the gastrointestinal organ system or in the lungs, but they may occasionally be found in other organs. Case: We describe a 56-year-old woman suffering from a carcinoid syndrome caused by a large serotonin-secreting pituitary tumour. She had suffered for years from episodes of palpitations, dyspnoea and flushing. Cardiac disease had been suspected, which delayed the diagnosis, until blood tests revealed elevated serotonin and chromogranin A in plasma. The somatostatin receptor (SSR) scintigraphy showed a single-positive focus in the region of the pituitary gland and MRI showed a corresponding intra- and suprasellar heterogeneous mass. After pre-treatment with octreotide leading to symptomatic improvement, the patient underwent trans-cranial surgery with removal of the tumour. This led to a clinical improvement and to a normalisation of SSR scintigraphy, as well as serotonin and chromogranin A levels. Conclusion: To our knowledge, this is the first reported case of a serotonin-secreting tumour with a primary location in the pituitary. European Journal of Endocrinology (2014) 170, K5–K9 European Journal of Endocrinology Introduction The carcinoid syndrome consists of a variety of symptoms neuroendocrine tumour (NET), most often located in the which typically include episodes of dry flushing with or gut or in the lungs.
    [Show full text]
  • (MPN) Symptoms
    RECOGNIZING SYMPTOMS RECOGNIZING YOUR MPN SYMPTOMS The MPN LANDMARK SURVEY* is a large-scale analysis of patients with myeloproliferative neoplasms (MPNs) and Healthcare Professionals (HCPs) who treat these rare, chronic blood cancers (813 patients; 457 hematologists/oncologists). The results from LANDMARK provide new information that validates previous findings about the effect of MPN symptoms and their impact on the lives of patients, even those with low-risk MPNs. Fatigue is a symptom of particular note. Across diseases it was reported as the most common and severe symptom, and the one that patients most wanted to resolve. Symptoms such as fatigue can be vague and challenging to quantify. It is difficult to measure tiredness and its impact on daily life. In addition to physical symptoms, patients in the survey reported emotional difficulties—feeling irritable, angry or depressed. Many patients surveyed suffered with their MPN symptoms for a year or more before diagnosis. LANDMARK helps to confirm that MPN symptoms have a significant, negative impact on daily activities and quality of life, often resulting in limited or canceled family and/or social activities. For some, it means having to miss days from work, reduce hours, or even leave their job. These issues create stress, anxiety, and financial hardship for MPN patients. This information is intended to help patients validate the impact of MPN symptoms and know that they are not alone. SYMPTOM RECOGNITION Patients in the survey often did not recognize the connection between certain symptoms they were experiencing and their MPN. For example, patients with MPNs often have difficulty sleeping; however, some patients who reported this symptom did not realize it was related to their MPN.
    [Show full text]
  • Pain Assessment and Treatment in Children with Significant Impairment of the Central Nervous System Julie Hauer, Amy J
    CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Pain Assessment and Treatment in Julie Hauer, MD, FAAP, a, b Amy J. Houtrow, MD, PhD, MPH, FAAP, c SECTION ON HOSPICE ChildrenAND PALLIATIVE MEDICINE, COUNCIL With ON CHILDREN Significant WITH DISABILITIES Impairment of the Central Nervous System Pain is a frequent and significant problem for children with impairment abstract of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of aComplex Care Service, Division of General Pediatrics, Boston medications for pain treatment. Behavioral pain-assessment tools are Children’s Hospital, Assistant Professor, Harvard Medical School, Boston Massachusetts; bSeven Hills Pediatric Center, Groton, reviewed in this clinical report, along with other strategies for monitoring Massachusetts; and cDepartment of Physical Medicine and Rehabilitation, University of Pittsburgh, Pediatric Rehabilitation pain after an intervention. Sources of pain in this population include Medicine, Rehabilitation Institute, Children’s Hospital of Pittsburgh of acute-onset pain attributable to tissue injury or inflammation resulting UPMC, Pittsburgh, Pennsylvania in nociceptive pain, with pain then expected to resolve after treatment Dr Hauer conceptualized and drafted the initial manuscript, reviewed and responded to questions and comments from all reviewers, and directed at the source. Other sources can result in chronic intermittent pain contributed to writing the final manuscript; Dr Houtrow contributed that, for many, occurs on a weekly to daily basis, commonly attributed to to the initial drafting and editing at all stages, including the final manuscript; and all authors approved the final manuscript as gastroesophageal reflux, spasticity, and hip subluxation.
    [Show full text]
  • Carcinoid Syndrome
    Practice Clinical images Carcinoid syndrome Habib ur Rehman MBBS 72-year-old man was admitted to hospital with con- gestive heart failure, weight loss and chronic diar- A rhea. He had flushing of the face and cyanosis, and telangiectasia were present in the cheek area (Figure 1). A contrast-enhanced computed tomography scan of the liver showed multiple masses with ring enhancement that were compatible with metastases (Figure 2). An echocardio- gram showed right-sided dilation of the heart with severe tri- cuspid regurgitation. The patient’s aortic, mitral and pulmonic valves were normal in structure and function. A 24-hour urine collection showed a total output of 5-hydroxyindoleacetic acid of 1515 (normal 0–43) μmol/L. A biopsy of the liver with immunostaining for chromogranin and synaptophysin were strongly positive and confirmed a diagnosis of metasta- tic carcinoid syndrome. The patient died 4 months later. A carcinoid tumour is a rare neuroendocrinologic malig- nancy that commonly originates from enterochromaffin cells in the gastrointestinal tract. The rate of incidence of carcinoid tu- mours has increased from 1.09 cases per 100 000 in 1973 to 5.25 cases per 100 000 in 2004, with a median age at diagnosis of 63 years.1 This increase has likely resulted from improve- ments in the classification of such tumours and from more wide- spread use of certain diagnostic screening tools such as en- doscopy. Carcinoid syndrome occurs when cells from the tumour metastasize to the liver and vasoactive substances enter systemic circulation via the hepatic vein. Flushing involving the face and upper trunk are the most prominent cutaneous signs.
    [Show full text]